Safety and Efficacy of Frameless Stereotactic Brain Biopsy Techniques

Chin Med Sci J June 2013

Vol. 28, No. 2 P. 113-116

CHINESE MEDICAL SCIENCES JOURNAL ORIGINAL ARTICLE

Safety and Efficacy of Frameless Stereotactic Brain Biopsy Techniques Qiu-jian Zhang1, Wen-hao Wang1*, Xiang-pin Wei2, and Yi-gang Yu1 1

Department of Neurosurgery, Xiamen University Southeast Hospital, Zhangzhou 363000, China

2

Department of Neurosurgery, Anhui Medical University Shengli Hospital, Hefei 230001, China

Key words: stereotaxis; frameless; biopsy; histology Objective To explore the safety and efficacy of frameless stereotactic brain biopsy. Methods Diagnostic accuracy was calculated by comparing biopsy diagnosis with definitive pathology in 62 patients who underwent frameless stereotactic brain biopsy between January 2008 and December 2010 in Xiamen University Southeast Hospital. Preoperative characteristics and histological diagnosis were reviewed and then information was analysed to identify factors associated with the biopsy not yielding a diagnosis and complications. Results Diagnostic yield was 93.5%. No differences were found between pathological diagnosis and frozen pathological diagnosis. The most common lesions were astrocytic lesions, included 16 cases of low-grade glioma and 12 cases of malignant glioma. Remote hemorrhage, metastasis, and lymphoma were following in incidence. Multiple brain lesions were found in 17 cases (27.4%). Eleven cases were frontal lesions (17.7%), 8 were frontotemporal (12.9%), 6 were frontoparietal (9.7%), and 5 each were temporal, parietal, and parietotemporal lesions (8.1%). Postoperative complications occurred in 21.0% of the patients after biopsies, including 10 haemorrhages (16.1%) and 3 temporary neurological deficits (1 epilepsy, 1 headache, and 1 partial hemiparesis). No patient required operation for hematoma evacuation. Conclusion Frameless stereotactic biopsy is an effective and safe technique for histologic diagnosis of brain lesions, particularly for multifocal and frontal lesions.

Chin Med Sci J 2013; 28(2):113-116

F

RAME-BASED techniques have been the standard

procedures in terms of morbidity, mortality, and diagnostic

method to achieve a reliable and accurate

yield.1,2 Recently, frameless stereotaxis has been rapidly

sampling of intracranial lesions and have been

embraced by most neurosurgeons to the extent that it is

shown

quickly supplanting frame-based techniques in general

to

be

superior

to

freehand

biopsy

neurosurgical practice. Some reports have suggested that

Received for publication September 12, 2012.

frameless techniques are as good as or better than the

*Corresponding author Tel: 86-13605007900, E-mail: 13605007900@

traditional frame-based approaches.3,4 The relative diagnostic

163.com

yield and candidacy of frameless as well as its complications

114

CHINESE MEDICAL SCIENCES JOURNAL RESULTS

are areas for ongoing debate. Thus the relative role of frameless in neurosurgical practice warrants further study.

June 2013

Altogether 62 patients were selected in the present study, including 33 males and 29 females. The median age

PATIENTS AND METHODS

was 43.2±16.7 years (range, 11-72 years). Table 1 summarizes the information of the patients and the events

Patients A consecutive series of patients who had undergone frameless image-guided stereotactic intracranial biopsy at the Department of Neurosurgery of Xiamen University Southeast Hospital from January, 2008 to December, 2010 were studied. The information of all the patients were entered into, and followed with a retrospective clinical outcomes database. General features (age, gender) were retrospectively collected from patient records. Patients with multifocal solid lesions underwent stereotactic biopsy only if they did not have a history of primary-histology-proven malignancy, and only if systemically examined with chest, abdomenal, and pelvis computed tomography (CT).

related to frameless stereotactic biopsy. Most cases were with multiple lesions (17/62, 27.4%), and the lesions with the highest frequencies were frontal (11/62, 17.7%), frontotemporal (8/62, 12.9%), frontoparietal (6/62, 9.7%), and temporal, parietal, parietotemporal lesions (all 5/62, 8.1%) (Table 2). Of the 62 consecutive diagnostic biopsies performed, pathological histological diagnosis was obtained in 93.5%. The 62 cases included 51 cases of neoplastic lesions and 11 cases of non-neoplastic lesions (Table 3). The most common diagnosis was astrocytic tumors, including 16 cases of low-grade glioma and 12 cases of malignant glioma, followed by remote hemorrhage (7 cases), metastasis (6 cases), and lymphoma (6 cases). In 10 cases, hemorrhage was noted in postoperative

Preoperative neuroimaging characteristics The sites of lesions were identified with preoperative CT or magnetic resonance imaging. Information about events associated with the operation, such as biopsy method used and postoperative complications were extracted from the operation report and patient records. The diagnoses were

CT (16.1%). The other postoperative complications included epilepsy, symptomatic headache, and partial hemiparesis (all 1/62, 1.6%). Table 1. Preoperative characteristics and symptoms and signs related to biopsy (n=62)

obtained from the pathological reports. Features

Number of cases

Percentage (%)

Frameless image-guided stereotactic biopsy

Male

33

53.2

Contrast-enhanced magnetic resonance imaging (pre- and

Female

29

46.8

post-contrast T1-weighted, 2-mm slices) scans were

Headache

27

43.5

conducted a maximum of 24 hours before the operation. All

Epilepsy

22

35.5

Motor weakness

11

17.7

7

11.3

the operation were performed under general anaesthesia and the patients’ heads were fixed in a three-point Mayfield clamp (Integra LifeSciences Corp., Plainboro, NJ, USA). Intraoperative

image

guidance

was

performed

using

neuronavigation (BrainLab AG, Heimstetten, Germany). The surgical plan, and thus the entry point, biopsy target, and needle trajectory, were determined preoperatively using

Lalopathy Cerebellar signs

3

4.8

Tinnitus

1

1.6

Mental disorder

1

1.6

Table 2. Preoperative anatomical localization of the lesions chosen for biopsy

neuronavigation. After registration was completed and the accuracy of the neuronavigation system confirmed using

Location

Number of cases

Percentage (%)

anatomic landmarks, burr hole craniotomy was performed.

Multiple lesions

17

27.4

The needle was then attached to the Mayfield clamp and held

Frontal

11

17.7

with a burr hole fixation needle trajectory guide.

Temporal

5

8.1

Parietal

5

8.1

Statistical analysis

Insular lobe

1

1.6

The enumeration data were expressed as number of cases

Frontotemporal

8

12.9

and percentage. In order to analyse factors relating to the

Frontoparietal

6

9.7

Parietooccipital

1

1.6

Parietotemporal

5

8.1

Temporooccipital

3

4.8

sites of lesion, and postoperative complications related to frameless stereotactic biopsy, the variables were explored univariately.

Vol. 28, No.2

CHINESE MEDICAL SCIENCES JOURNAL

115

Table 3. Definitive histological diagnosis and biopsy-related

lesion, Woodworth et al5 reported that large lesions, with a

diagnosis (n = 62)

maximum diameter greater than 2 cm, were 5-fold more

Lesions

Pathological

Frozen pathological

diagnosis (n)

diagnosis (n)

Neoplastic

likely to yield a diagnostic biopsy. The data of the present study support the notion that frameless stereotactic biopsy is an effective method to establish tissue diagnosis for intracranial lesions. The

Low-grade glioma

16

13

Malignant glioma

12

11

Lymphoma (NHL B cell)

6

6

Metastasis

6

6

Gliosis

5

7

Mixed glioma

3

3

Hemangioma

2

3

Yolk sac tumor

1

1

Hemorrhage

7

8

side-cutting needle, which has the advantage of preserving

Cysticercosis

2

2

a core of intact cross-sectional tissue architecture,

Tuberculosis

2

2

facilitating histological interpretation. Multiple sections

Non-neoplastic

diagnostic yield of frameless stereotaxy in this study is 93.5%, within the range of diagnostic yield (90%-96%) previously reported.5-9 The diagnostic yield reported by Owen et al3 was 90.9%. Dammers et al4 reported an overall diagnostic yield of 89.4% (89.7 and 88.9% for frame-based and frameless biopsy procedures, respectively). The specific method and number of biopsy bits likely play a key role in determining diagnostic accuracy and yield. As other researchers did,5,9,10 we tended to select a

were taken with the needle at serial depths along the single trajectory. This method allows the obtainment of different

DISCUSSION

tissues at different depths, providing samples of normal

The treatment of intracranial lesions largely depends

brain, lesion edge, and central contents. The utility of this

on the histological diagnosis. Frameless stereotactic

approach was reflected in the diagnostic accuracy except

technique (also called frameless neuronavigation) has

for 4 cases in this study. The 4 cases were confirmed finally

been accepted as a feasible tool for intracranial biopsy with

(2 cases of gliosis and 2 cases of remote hemorrhage). Jain

good accuracy and little mortality, compared with frame-

et al11 found that the diagnostic accuracy increased from

based techniques which have been considered as the gold

76.5% for single biopsies to 84% and 88.2% for 2 and 3

1,2

Given the

samples, respectively, and 100% for biopsies with 5 to 6

increasing popularity of frameless neuronavigation systems in

samples. A contrary view was offered by Dammers et al,4

stereotactic biopsy, it may be helpful to establish criteria

who reported no relationship between the number of tissue

for patients selection through which we could determine

samples and the diagnostic yield.

standard for sampling intracranial lesions.

the suitability of frameless stereotactic techniques. In the

An important use of frameless stereotactic biopsy is

present study, lesions had to satisfy anatomic location

confirming tissue diagnosis for patients with neoplastic

conditions besides being at least 15-mm in size. Lesions at

brain lesions. In the present study, astrocytic lesions were

the following locations were excluded: (1) infratentorial,

the most common, including 16 cases of low-grade glioma

basalganglia, thalamus, or pineal; (2) adjacent to the

and 12 cases of malignant glioma. Twenty-four of the 62

Circle of Willis or root of the sylvian fissure. Owen et al3

patients who had a definite histological or microbiological

reported that 80% lesions are candidates for frameless

diagnosis on needle biopsy subsequently underwent open

stereotactic techniques, and the remaining 20% small or

craniotomy following the original biopsy. Review of these

deeply

pathology results were in accordance with those obtained

seated

lesions

still

depend

on

frame-based

stereotaxy. The anatomical location of the lesion might have influence on both the diagnostic yield and the risk of

with the frameless stereotactic needle biopsy. It is important to understand the practical safety of

complications. Due to postoperative hemorrhage or edema,

frameless stereotactic biopsy. Damage to blood vessels in

a deeply seated lesion at the midline or sylvian fissure is

the biopsy trajectory is often unavoidable, due to the

associated with a higher incidence of complication or not

surgeon’s inability to directly see the result of manipulation.

obtaining a diagnosis on histopathologic examinaion. In

A distinct advantage of software for pre-surgical planning

this study, a lesion located in the insular lobe with a

with the frameless biopsy technique is that the surgeon is

maximum diameter of 20 mm was not revealed in the

able to scroll through the trajectory path and plan to avoid

histological diagnosis. The reason was brain shift resulted

crossing pial and arachnoid surfaces in order to reduce the

from cerebrospinal fluid diversion. Concerning the size of

risk of hemorrhage. In the patients in this study, Z-Touch

116

CHINESE MEDICAL SCIENCES JOURNAL

system was applied for pre-surgical planning, and little

5.

June 2013

Woodworth GF, McGirt MJ, Samdani A, et al. Frameless

blood was noted in the needle or the specimen during the

image-guided

procedure. The subsequent bleeding was found at the

diagnostic yield, surgical morbidity, and comparison with

biopsy site on post-biopsy CT. Only 3 patients developed new clinical temporary neurological symptoms (1 epilepsy,

stereotactic

brain

biopsy

procedure:

the frame-based technique. J Neurosurg 2006; 104:233-7. 6.

Ferreira MP, Ferreira NP, Pereira Filho Ade A, et al.

1 headache, and 1 partial hemiparesis) and no one

Stereotactic computed tomography-guided brain biopsy:

developed permanent new neurological symptoms. No

diagnostic yield based on a series of 170 patients. Surg

patient required operation for cerebrospinal fluid diversion or for hematoma evacuation as a result of frameless

Neurol 2006; 65 Suppl 1:S1:27-1:32. 7.

stereotactic biopsy.

Kim JE, Kim DG, Paek SH, et al. Stereotactic biopsy for intracranial lesions: reliability and its impact on the planning of treatment. Acta Neurochir (Wien) 2003;

REFERENCES 1.

145:547-54. 8.

3.

M,

Robson

DK,

et

al.

9.

Smith JS, Quiñones-Hinojosa A, Barbaro NM, et al.

Wen DY, Hall WA, Miller DA, et al. Targeted brain biopsy: a

Frame-based stereotactic biopsy remains an important

comparison of freehand computed tomography-guided and

diagnostic tool with distinct advantages over frameless

stereotactic techniques. Neurosurgery 1993; 32:407-12.

stereotactic biopsy. J Neurooncol 2005; 73:173-9.

Owen CM, Linskey ME. Frame-based stereotaxy in a

10.

Field M, Witham TF, Flickinger JC, et al. Comprehensive

frameless era: current capabilities, relative role, and the

assessment of hemorrhage risks and outcomes after

positive- and negative predictive values of blood through

stereotactic brain biopsy. J Neurosurg 2001; 94:545-51.

the needle. J Neurooncol 2009; 93:139-49. 4.

Tsegaye

in a clinical case series. Br J Neurosurg 2006; 20:222-6.

masses: stereotactic or freehand biopsy? Br J Neurosurg 2.

N,

Stereotactic brain biopsy: an audit of sampling reliability

Lee T, Kenny BG, Hitchock ER, et al. Supratentorial 1991; 5:331-8.

Shastri-Hurst

11.

Jain D, Sharma MC, Sarkar C, et al. Correlation of

Dammers R, Haitsma IK, Schouten JW, et al. Safety and

diagnostic yield of stereotactic brain biopsy with number

efficacy of frameless and frame-based intracranial biopsy

of biopsy bits and site of the lesion. Brain Tumor Pathol

techniques. Acta Neurochir (Wien) 2008; 150:23-9.

2006; 23:71-5.

1